DOI: 10.1111/1471-0528.13165 www.bjog.org

Oral and Poster Presentations The following abstracts have been accepted and presented at the National Trainees Conference, 27–28 November 2014, Manchester. Abstract numbers represent the number allocated at submission. Abstracts which were rejected, withdrawn, or not presented do not appear in this supplement. Disclaimer: This supplement has been produced using author-supplied copy. Editing has been restricted to some corrections of spelling and style where appropriate. No responsibility is assumed for any claims, instruction, methods or drugs dosages contained in the abstracts: it is recommended that these should be verified independently. 0002 Case report: progesterone induced dermatitis

Tingi, E; Watson, A Tameside General Hospital, Ashton Under Lyne, United Kingdom Background: Autoimmune progesterone dermatitis (APD) is a very rare manifestation of allergy to progesterone, which appears as skin condition in women and recurs in a cyclical manner corresponding to their menstrual cycles. It is thought to be associated with a previous history of exogenous progesterone intake and sometimes with pregnancy, and it may also appear without such a background. Case: A 41-year-old woman was referred to the outpatient gynaecological clinic for an opinion having been under the care of dermatologists with severe chronic idiopathic urticaria. However, the symptoms were much worse during the week prior to her menstrual cycles and resolved with the start of menstruation. A diagnosis of progesterone sensitive urticaria was considered, therefore monthly Prostap injections and Oestradiol 2 mg orally once daily commenced for three months. At 3-month follow-up, she reported significant improvement of her symptoms with the initial treatment. She was offered to either continue with Prostap injections plus the addition of Mirena Coil or Total abdominal hysterectomy (TAH) and bilateral salpingoophorectomy (BSO). The patient chose to undergo the major surgery. Conclusion: We report a case of APD that was initially diagnosed as chronic idiopathic urticaria and treated without symptomatic improvement. APD should be included in the differential diagnosis for every woman of reproductive age, who presents with recurrent eczema which is not relieved with common medical treatment.

0003 How can the management of postpartum haemorrhage in the UK be compared to that in developing countries?

Botchey, S-A1,2 1

University of liverpool, Medical School, Liverpool, United Kingdom; Blackpool Teaching Hospitals, Blackpool, United Kingdom


Introduction: Primary postpartum haemorrhage (PPH) is the

most common form of major obstetric haemorrhage and accounts

for 25% of global maternal deaths. Over 2/3 of these deaths occur in sub-Saharan Africa. This calls for improvement in education and protocols for PPH management tailored to developing countries. The author aims to extrapolate and tailor UK PPH management strategies to developing countries. Methods: Research was conducted over a period of 5 months at Blackpool Victoria Hospital (BVH) including a week spent in Korle Bu teaching hospital, Ghana. The PPH management guidelines used in the BVH and Korle Bu Hospitals were reviewed against the Royal College of Obstetricians and Gynecologists (RCOG) PPH management guidelines. In addition, the management of two cases of PPH at BVH and one case at Korle Bu Hospital were assessed. Results: The PPH management protocol in BVH closely mirrored the RCOG recommendations and was effective in management of the cases. However, minor improvements can be made to the BVH guidelines such as specifying time intervals for monitoring vital signs. The case in Ghana was managed adequately and key recommendations have been suggested for the Ghana PPH guidelines such as early alerting and involvement of senior staff. Conclusion: Four key recommendations have been formulated for improving PPH management in developing countries. These include training and regulation, use of cheaper surgical methods, adequate use of uterotonics and efficient resuscitation techniques.

0004 Management of massive secondary postpartum haemorrhage complicated by uterine perforation with the use of Bakri Balloon

Ejaz, H; Khan, Z; Kuntal, S; Kevelighan, E Singelton Hospital, Swansea, Wales, United Kingdom Background: The authors aim to alert obstetricians about the use of Bakri Balloon in the management of secondary postpartum haemorrhage. Case: A 34-year-old para 6 had a preterm caesarean delivery at 36 weeks and 4 days. Five days postpartum, she was re-admitted with a history of lower abdominal pain and fever. Pelvic ultrasound suggested haematoma anterior to the uterus. She received intravenous antibiotics and was discharged after 2 days, 6 days later, she re-admitted with similar complaints. Repeat ultrasound was suggestive of 5 cm 9 4 cm 9 3 cm retained products of conception and hydronephrosis of left kidney confirmed on CT

ª 2014 The Author BJOG: An International Journal of Obstetrics and Gynaecology ª 2014 RCOG


Oral and Poster Presentations

scan as left ureteric obstruction. The obstruction was treated as left nephrosotmy. She had an episode of secondary postpartum haemorrhage, which was managed conservatively. On day 26, she had another episode of massive postpartum haemorrhage. Conservative management including five doses of Carboprost, was unsuccessful 400 ml of products of conception were removed after suction evacuation. Histology revealed products of conception. Due to persistent bleeding a Bakri Balloon was inserted. As the balloon was inflated to 200 ml, uterine perforation was suspected due to loss of resistance and decision made for urgent laparotomy. A fundal perforation was found extending from one cornual end to other end. Hysterectomy was performed. She required transfusion. She made an excellent recovery. Conclusion: Massive secondary postpartum haemorrhage can be life threatening as significant morbidity/mortality may occur. Usually, secondary postpartum haemorrhage is associated with retained products of conception, placental membrane and endometritis. Antibiotics are the main stay of traetment. Surgical intervention is required if bleeding persists. The sequential use of uterine curettage and balloon temponade in the aetiology of uterine rupture is a rare occurance. We suggest that infection decreases the strength of the uterine wall and the use of Bakri Balloon in such cases may increase the risk of uterine perforation and perhaps should be avoided. Alternative methods including B Lynch suture may be considered.

Recurrence rates vary between 30 and 90%. Those fetuses surviving the first trimester often have a poor outcome including in utero growth retardation and stillbirth. Diagnosis involves laboratory testing for CD68 immunstaining.

0006 Histiocytic intervillositis: a rare but important cause of miscarriage

Vanes, NK; Srinivasan, M; Ganapathy, R

Vanes, NK; Sadrudin, F; Mukherjee, S University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom Case: We present TS, a 29-year-old, para 0 lady, who was referred

for consultant led antenatal care following a medical termination of pregnancy (TOP) at 16/40 due to fetal intrauterine death. Histology revealed histiocytic intervillositis as the cause of death which is a condition where mononuclear inflammatory cell infiltrate in the intervillous space of the placenta which can result in spontaneous and recurrent miscarriages. Case reports have shown success on prednisolone from the first trimester, therefore TS was started on a regime of 20 mg prednisolone until 20/40, 10 mg until 28/40, and 5 mg until 32/ 40. She was also prescribed aspirin 75 mg OD and cyclogest 400 mg BD until 32/40. Sporadic PV bleeding occurred at 17 weeks of gestation. At 20 + 1, 4 episodes of light bleeding occurred, but no abdominal pain. Placenta praevia was diagnosed at 20 weeks of gestation. At 36/40, the fetus was cephalic presentation, liquor was normal and placenta anterior upper and therefore was allowed a normal vaginal delivery. A Nevielle Barnes forceps delivery was required due to prolonged second stage. The placenta was sent to a tertiary centre experienced with the condition. Conclusion: Histiocytic intervillositis is a rare condition which is diagnosed in around 1% of all miscarriages. The aetiology remains uncertain and is thought to be of immunological in origin.


0007 Concealed haematometra causing chronic upper abdominal pain

Wali, S1; Chatterjee, J1; Zeegen, R2; Smith, JR1 1

Queen Charlotte’s and Chelsea Hospital, London, United Kingdom; Chelsea & Westminster Hospital, London, United Kingdom


Background: One of the common complications of endometrial ablation for menorrhagia, as shown in this case, is haematometra as a result of occlusion of the upper genital tract. This would typically cause a feeling of fullness and tenderness in the lower abdomen that may be cyclical. Case: This case presents a diagnostic challenge in that the patient’s pain was constant and located in her upper abdomen, a location not typically associated with gynaecological pathology.

0008 Metastatic adenocarcinoma of rectum presenting in labour City Hospital, Birmingham, Birmingham, United Kingdom Case: We present a 21-year-old, G3P2, 37 weeks of gestation who was admitted with the lower abdominal pains and vomiting. She gave a history of constipation for 1 week. There was no history of bleeding per rectum. She was admitted and was treated for dehydration with intravenous fluids. She underwent emergency caesarean section with the suspicion of abruption. During caesarean section there was ascites and dilated bowel loops. She deteriorated in the postoperative period with worsening abdominal distension and vomiting. CT abdomen was performed which suggested distended large bowel loaded with possible collapse of the lower end of sigmoid and rectum secondary to postpartum uterus. Emergency laparotomy on the third postoperative period was performed due worsening clinical picture of abdominal distension. During laparotomy there was a rectal growth with dilated colon and areas of necrosis of the colon undergoing semi colectomy with ileostomy and mucus fistula of the sigmoid colon. She recovered well in the postoperative period and she is waiting for further investigations and MRI. The resected bowel specimen revealed the combination of goblet cell carcinoid and a poor differentiated adenocarcinoma. Conclusion: Goblet cell carcinoid tumours (GCC) can be separated into 2 morphological groups namely typical GCC (100% 5-year survival) and poorly differentiated type (0% 5-year survival). Although constipation is the most common symptom women present in pregnancy, rectal carcinoma is the rarest cause. There are case reports of rectal carcinoma presenting as obstructed

ª 2014 The Author BJOG: An International Journal of Obstetrics and Gynaecology ª 2014 RCOG

Oral and Poster Presentations

labour in pregnancy, however in this case she underwent caesarean section in early labour there were signs of obstruction with bladder drawn up and lower segment of uterus being oedematous. Incidence of Colorectal carcinoma in pregnancy is around 0.002%. Adenocarcinoma of the rectum do present in the 2nd and 3rd decade. Goblet cell carcinoma do present between 5th and 6th decades. This is an unusual combination.

0009 A rare case of a leiomyosarcoma

Thomas, K; Rambocas, N Sangre Grande Regional Hospital, Sangre Grande, Trinidad and Tobago Case: Our case involves a postmenopausal female with a vulval lesion for about 5 months duration. On examination, this lesion measured 6 cm 9 6 cm and was exophytic and vascular. A vulvar biopsy revealed a leiomyosarcoma. The patient went on to have a vulvectomy and bilateral groin node dissection. The groin nodes were negative but due to the close surgical margins, further therapy was offered in the form of chemoradiation. (Digital photographs are provided.)

0011 Conservative management of adnexal torsion followed by ipsilateral tubal pregnancy: two case reports

Moussa, M; Hassan, M Ain Shams University, Cairo, Egypt Background: Conservative management of adnexal torsion is commonly adopted by gynaecologists. However, long term consequences of detorsion in terms of tubal function and fertility outcomes are lacking. Case 1: A 23-year-old, para 2 woman presented with lower abdominal pain and vomiting. She was vitally stable with lower abdominal tenderness particularly on the right side. Investigations revealed leukocytosis and pregnancy test negative. Colored Doppler ultrasound revealed adnexal mass suspicious for torsion. Laparotomy confirmed the diagnosis and detorsion with oophoropexy was performed. Normal ovarian function was documented after 3-months. 14-months later, the patient developed ipsilateral tubal pregnancy and managed by salpingectomy. Case 2: A 21-year-old, para 1 presented with similar symptoms and had similar diagnostic evaluation. She was diagnosed as adnexal torsion and managed by detorsion and oophoropexy. During follow-up, the patient developed ipsilateral tubal pregnancy and managed by salpingectomy. Conclusion: Though adnexal detorsion usually restore the ovarian function within a few months, the tubal integrity might be impaired and hence predispose to tubal pregnancy.

0012 An audit of surgical management of ectopic pregnancy in a district general hospital

Antoun, L; Hollingworth, J Queen’s Hospital, Burton-on-Trent, United Kingdom Introduction: We aim to review the surgical management of

ectopic pregnancy benchmarked against the RCOG guidelines. Other criteria were derived from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). Methods: This is a retrospective case note analysis of 73 cases of patients with surgically treated ectopic pregnancies between September 2012 and March 2014. The study was conducted at Queen’s Hospital, Burton. Information was collected regarding the demographics, risk factors for ectopic pregnancy, presentation, Rh status, delay in diagnosis, procedure undertaken, length of hospital stay, operative and postoperative complications, involvement of contralateral tube, grade of operating surgeon, time of the surgery, and follow-up plans. Results: Mean age of women was 30.2 years. The most common presenting symptom was abdominal pain (97.5%). Past histories of laparotomy and previous PID compromised (20.5%) of the patients. 44% of the patients were diagnosed from the 1st EPAU scan, whilst 9% were still not diagnosed even after the 2nd scan. 72% of patients had definite surgical intervention from the first admission, whilst 28% had to be re-admitted for the definite management. 29.5% of the patients had to wait for more than 24 hour before the definitive management was carried out. The performed procedure (laparoscopic salpingectomy n = 44, laparoscopic salpingotomy n = 18, laparotomy n = 9). 5.4% of patients had significant drop in Hb post-op, 78% of patients were discharged the following day post-op. 50% of patients didn’t have follow-up plans. 98% of all procedures were performed during official working hours. A consultant was present in all cases. Conclusion: There is a good compliance with the national standard, as well as (NCEPOD) recommendation, with laparoscopic management being the more beneficial, safe, and efficient way of management. However, there is still room for improvement in identifying patients with ectopic pregnancy, as well as USS pick up rate.

0013 Audit of clinical outcomes from total laparoscopic hysterectomies at Southmead Hospital, Bristol, September 2009–2013

O’Brien, S; Munro, K; Vyas, S Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom Introduction: Total laparoscopic hysterectomy (TLH) is a

relatively newly established treatment for endometriosis, and developing practice needs to be audited to ensure safety and efficacy. Methods: We analysed all TLHs performed at Southmead Hospital, Bristol, a Regional Endometriosis Referral Centre between

ª 2014 The Author BJOG: An International Journal of Obstetrics and Gynaecology ª 2014 RCOG


Oral and Poster Presentations

September 2009 and September 2013 (142 procedures). We looked at standard surgical markers including Estimated Blood Loss (EBL), Operative Time (OT), Length of Stay (LoS), and VTE prophylaxis. We looked at adverse clinical outcomes, both early and late, as measured in the Cochrane Review ‘Surgical approach to hysterectomy for benign gynaecological disease’ (2009). Results: We showed that despite undertaking more complex procedures than those used in Cochrane, we had comparable levels of complications such as ureteric injury, transfusion, postoperative urinary tract and bowel dysfunction. We also found a lower EBL (199 ml versus 340 ml) than reported in the Cochrane review, as well as shorter OT (97 min versus 112 min) and LoS (1.8 days versus 3.2 days). Conclusion: We found a significant number of emergency re-admissions (23), the majority of whom (14) were admitted with pain or minor infections, which settled with analgesia or oral antibiotics. Therefore we could potentially reduce readmissions by increasing patient knowledge and self-care in the recovery period; by patients’ improved use of analgesia, and presenting earlier to GP’s with symptoms of minor infections, allowing infections to be managed as an outpatient. We hope to do so with a new patient information leaflet.

0014 Not all haematesis in pregnancy is due to a benign cause

Abdul-Hamid, R; Beharrysingh, K; Rambocas, N Sangre Grande Regional Hospital, Sangre Grande, Trinidad and Tobago Case: A 27-year-old P1 + 0 female presented to the gynaecology

ward at 11 weeks pregnant with severe vomiting. On examination, she was clinically dehydrated with no other abnormal signs. She responded well to intravenous hydration and antiemetics. A pelvic ultrasound also confirmed a viable intrauterine pergnancy compatible with her dates. However on the 3rd day of admission, she complained of several episodes of haematesis. An upper GIT endoscopy was scheduled for the following day. At the time of endoscopy, she was noted to have a pharyngeal mass which was necrotic and vascular. The endoscopy did not reveal any other abnormalities like tears or ulcers. Upon completion of this procedure, the patient developed severe stridor and had a respiratory arrest. She had to be intubated and ventilated. A non-contrasted CT scan of her neck and chest showed a large pharyngeal mass about 6 cm across with extension into the retropharyngeal space. There were also a few enlarged lymph nodes. It suggested that this could represent an infective process. Urgent ENT advise was sought. Following this, the patient went onto to have excision of this lesion under general anaesthetic. The growth was about 6 cm 9 5 cm with extension into the piriform fossa. Complete excision could not guaranteed. It was thought that this growth could be either a pyogenic granuloma or a benign lesion. She made a good postoperative recovery and was subsequently discharged with joint ENT and obstetric follow-up. The


histology of this mass showed an embryonal rhabdomyosarcoma.

0015 Benign pelvic mass associated with raised serum CA125 levels: a case report

Antoun, L; El-Khanagry, M Queen’s Hospital, Burton-on-Trent, United Kingdom Background: Elevated levels of CA125 with clinical presentation of weight loss, intermenstrual bleeding, and associated pelvic mass is highly suggestive of ovarian malignancy, this creates a diagnostic dilemma with the knowledge that various benign pelvic conditions may have the same presentation. Case: We present a case of 28-year-old, para 1 Caucasian white woman who presented to the UCR clinic with lower abdominal pain, significant menorrhagia, intermenstrual bleeding, and weight loss. She was not using any contraception. Her last cervical screening test 3 years prior to her presentation was normal. She was treated for a Chlamydia infection 2 months earlier to her complaint. She had a past history of appendicectomy, had no allergies and was on no medication. On imaging she was found to have 4.9 cm 9 5.5 cm complex cystic mass in left adnexa, and vascular nodules with a raised CA125 of 632.4 which was initially thought to be highly suspicious of cancer, but was subsequently found to be due to a left tubo-ovarian abscess from the Chlamydia infection. Conclusion: This case demonstrates a high rate of misdiagnosis between ovarian malignancy and pelvic inflammatory disease, especially in young patients. The initial clinical suspicion was for a pelvic abscess but the findings of weight loss, intermenstrual bleeding, and markedly elevated CA125 level was highly suggestive of malignancy. It is very important to seek reviews of CT scan reports, and to screen for pelvic infection in these patients.

0016 Management of thrombotic thrombocytopenic purpura and pregnancy

Vanes, NK; Stevenson, H; Raman, S; Sinha, A City Hospital, Birmingham, United Kingdom Case A: 25-year-old, para 3 (NVD) was seen in antenatal clinic

with previous a previous history of Thrombotic Thrombocytopenic Purpura (TTP). She was admitted with a reduced conscious level, headaches and nausea 5 years previously and investigations showed a low Hb 6.8 and platelet count 11. ADAMTS13 was checked and found to be deficient (2 (OR 3.82, CI:1.58–9.62). There was no association with seniority of either obstetrician or anaesthetist, or with maternal BMI. Compared with spinal anaesthesia, unplanned general anaesthesia was associated with increased likelihood of several adverse maternal and fetal outcomes; >1.5 litres maternal haemorrhage (OR 5.67, CI:1.87– 13.96), critical incidents (OR 4.76, CI:1.76–11.05) and delayed neonatal respiration (OR 4.76, CI:1.76–11.05). Despite the increased likelihood of delayed neonatal respiration with unplanned general anaesthesia there was no increased likelihood of umbilical artery pH 2 g between booking and the routine 28 week bloods The FBC at the time of transfusion was also looked at. Only 61% had an Hb

Abstracts of the RCOG National Trainees Conference (NTC) 2014, 27-28 November 2014, Manchester, United Kingdom.

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